Idaho Natural Health Care
Services Disclosure Form

Please provide the following information:

* Name
Title
Business Name
* Address
* City
* State
* Zip Code
* Phone
FAX
* E-mail
URL

        * Enter the type of natural health care services you are providing, separated by commas:

        * Enter name of educational program(s) or apprenticeship(s), separated by commas:

        * Enter the name of school(s) or apprenticeship(s) and locations(s) (city, state), separated by commas:

NOTE:  THIS DISCLOSURE IS THE INTERPRETATION OF WHAT IS REQUIRED BY THE COALITION FOR NATURAL HEALTH.
IF YOU HAVE LEGAL CONCERNS, IT IS IN YOUR BEST INTEREST TO CONSULT AN ATTORNEY REGARDING
THE IDAHO NATURAL HEALTH CARE SERVICES DISCLOSURE.

After clicking the 'Complete' button, you may print the form by using the print button from your browser. 
If headers and footers appear on your printed copy, you may delete them by going to File, Page Setup, and deleting the information in the header and footer fields.  Then print your completed form again.

After clicking the 'Complete' button, you may return to this Disclosure Request Form by using the 'back' button on your browser.

NOTE:  The client shall receive a copy of the signed disclosure statement and the original is to be kept for a minimum of two (2) years.  If the information changes (i.e. address, etc), a new disclosure form is required.